Simultaneous cochlear implantation and removal of acoustic neuroma: implications for hearing.

OBJECTIVE: To present our data evaluating the feasibility of simultaneous cochlear implantation with resection of acoustic neuroma. METHODS: This paper describes a case series of eight adult patients with a radiologically suspected acoustic neuroma, treated at a tertiary referral centre in Newcastle, Australia, between 2012 and 2015. Patients underwent cochlear implantation concurrently with removal of an acoustic neuroma. The approach was translabyrinthine, with facial nerve monitoring and electrically evoked auditory brainstem response testing. Standard post-implant rehabilitation was employed, with three and six months' follow-up data collected. The main outcome measures were: hearing, subjective benefit of implant, operative complications and tumour recurrence. RESULTS: Eight patients underwent simultaneous cochlear implantation with resection of acoustic neuroma over a 3-year period, and had 25-63 months' follow up. There were no major complications. All patients except one gained usable hearing and were daily implant users. CONCLUSION: Simultaneous cochlear implantation with resection of acoustic neuroma has been shown to be a safe treatment option, which will be applicable in a wide range of clinical scenarios as the indications for cochlear implantation continue to expand.

Characteristics of deformity surgery in patients with severe and rigid cervical kyphosis (CK): results of the CSRS-Europe multi-centre study project.

INTRODUCTION AND PURPOSE: Little information exists on surgical characteristics, complications and outcomes with corrective surgery for rigid cervical kyphosis (CK). To collate the experience of international experts, the CSRS-Europe initiated an international multi-centre retrospective study. METHODS: Included were patients at all ages with rigid CK. Surgical and patient specific characteristics, complications and outcomes were studied. Radiographic assessment included global and regional sagittal parameters. Cervical sagittal balance was stratified according to the CSRS-Europe classification of sagittal cervical balance (types A-D). RESULTS: Eighty-eight patients with average age of 58 years were included. CK etiology was ankylosing spondlitis (n = 34), iatrogenic (n = 25), degenerative (n = 9), syndromatic (n = 6), neuromuscular (n = 4), traumatic (n = 5), and RA (n = 5). Blood loss averaged 957 ml and the osteotomy grade 4.CK-correction and blood loss increased with osteotomy grade (r = 0.4/0.6, p < .01). Patients with different preop sagittal balance types had different approaches, preop deformity parameters and postop alignment changes (e.g. C7-slope, C2-7 SVA, translation). Correction of the regional kyphosis angle (RKA) was average 34° (p < .01). CK-correction was increased in patients with osteoporosis and osteoporotic vertebrae (POV, p = .006). 22% of patients experienced a major long-term complication and 14% needed revision surgery. Patients with complications had larger preop RKA (p = .01), RKA-change (p = .005), and postop increase in distal junctional kyphosis angle (p = .02). The POV-Group more often experienced postop complications (p < .0001) and revision surgery (p = .02). Patients with revision surgery had a larger RKA-change (p = .003) and postop translation (p = .04). 21% of patients had a postop segmental motor deficit and the risk was elevated in the POV-Group (p = .001). CONCLUSIONS: Preop patient specific, radiographic and surgical variables had a significant bearing on alignment changes, outcomes and complication occurrence in the treatment of rigid CK.

Seatbelt: a double-edged sword.

Intra-abdominal vascular injury due to blunt trauma is unusual in children. Due to its rarity, detailed reports dealing with its management are scarce in paediatric literature. Diagnosis of these injuries is challenging, and a high degree of awareness is necessary for rapid identification and treatment of these injuries. We report the case of a child with seatbelt sign and mesenteric vein injury due to blunt trauma to the abdomen during a motor vehicle accident where the seatbelt was incorrectly placed. She also sustained cervical vertebral injury. The pattern of injuries in children in these situations may differ from that found in adults. While seatbelts have undoubtedly saved many lives, awareness about correct placement of these restraints is extremely necessary.

Serial spread of benign metastasizing leiomyoma to the thoracic spine.

Benign metastasizing leiomyoma (BML) is a rare condition due to a histologically benign smooth muscle tumour originating from a uterine leiomyoma. It rarely affects the spine to cause spinal cord compression. Here we report a patient with serial metastases to the thoracic spine causing neurological compromise. The rapid spread of BML in this patient illustrates an aggressive manifestation of a usually benign indolent tumour.

Transient global brainstem dysfunction after microvascular decompression of the trigeminal nerve.

Microvascular decompression of the trigeminal nerve root entry zone has become a standard treatment for trigeminal neuralgia. It has been widely reported with a low morbidity. This case report details an unusual and previously unreported complication of this procedure.

Surgical management of ruptured aneurysms in the eighth and ninth decades.

BACKGROUND: The surgical management of elderly patients with aneurysmal subarachnoid haemorrhage (SAH) is controversial. The present study was performed to more clearly define issues facing elderly SAH patients undergoing surgical repair of their aneurysms. METHOD: Between 1990 and 2000, 100 patients, aged 70 years or older, were managed consecutively with aneurysmal surgical repair at Verona City Hospital. Ninety-seven of these were analysed with regard to age, clinical grade on admission, radiological features, and specific management components (3 patients were excluded from further analysis because of inadequate follow up data). Surviving patients were followed up for a minimum of 6 months and clinical outcome was assessed. FINDINGS: Hydrocephalus requiring permanent CSF diversion occurred in 44% of cases surviving beyond 10 days from their SAH. The development of hydrocephalus requiring shunting was delayed more than 6 weeks in 7% of these cases. Medical complications occurred in 22% of cases. Clinical grade of haemorrhage (p<0.001), early hydrocephalus requiring ventriculostomy (p=0.003) and the development of medical complications (p=0.03) were significantly associated with poor outcome. Clinical vasospasm was not a major determinant of outcome in this group. The need for permanent CSF diversion was significantly associated with increasing age (p=0.03), intraventricular haemorrhage (p<0.001), early hydrocephalus requiring ventriculostomy (p=0.003) and the development of medical complications (p=0.05). INTERPRETATION: Elderly patients experience a different range of complications following aneurysmal subarachnoid haemorrhage than their younger counterparts. Clinicians should remain alert to the development of hydrocephalus, especially of delayed onset.

Spinal arteriovenous malformations: a review with case illustrations.

Spinal arteriovenous malformations are united by the existence of arteriovenous shunting but are quite heterogeneous in terms of pathology. Until recently, the pathological confusion has been such that management has been poorly understood and this is magnified by the rarity of the lesions. Type 1 AVMs, where the fistula is located in the dura, usually present with a venous hypertensive myelopathy and are relatively easily dealt with surgically. Type 2 AVMs, most closely mimicking the parenchymal AVMs of the brain, usually present with haemorrhage and may be surgically remediable but with much greater risk than the type 1 lesions. Type 3 AVMs, with a diffuse location through both the cord and extra-CNS tissue, usually present early in life with a myelopathy and are often untreatable. Type 4 AVMs, with a fistula located on the pial surface of the cord, usually present with a venous hypertensive myelopathy or subarachnoid haemorrhage, can be treated relatively easily by surgery when small but may be better treated endovascularly when the fistula is large. The purpose of this review is to summarise the current pathological, clinical and management literature with illustrative cases underscoring the important features of this heterogeneous disorder.

Barbiturate coma for severe, refractory vasospasm following subarachnoid haemorrhage.

OBJECTIVE: To document the outcome of patients treated with barbiturate coma for severe symptomatic angioplasty-resistant vasospasm. To compare mortality with that predicted by admission APACHE II score, and neurological outcome with that of historical controls treated with barbiturate coma for vasospasm, and with historical controls with delayed ischaemic deficits from vasospasm treated with nimodipine. DESIGN: Cohort study. SETTING: Neurosurgical Intensive Care Unit of tertiary referral university teaching hospital. PATIENTS: Eleven (6.7%) of 164 consecutive patients with aneurysmal SAH managed according to our protocol who were treated with thiopentone-induced burst suppression coma for severe symptomatic, angioplasty-resistant vasospasm. INTERVENTIONS: Chart, database and literature review. MEASUREMENTS AND RESULTS: All 11 patients survived to hospital discharge (mortality 0%) compared with first-day APACHE II predicted mortality of 30.6% (p=0.15). Outcome at 6 months was: good recovery 8/11 (72.7%), moderate disability 2/11 (18.2%), vegetative survival 1/11 (9.1%). Ten of 11 (90.9%) had a good neurological outcome compared with 50.6% of historical controls with delayed ischaemic deficit from vasospasm (odds ratio 9.78, 95% confidence interval 1.24-77.0, p=0.02), and 0% of previously reported patients treated with barbiturate coma for vasospasm (p < 0.01). CONCLUSION: Our results are better than previously published outcomes and suggest formal evaluation of barbiturate coma in the treatment of severe resistant symptomatic vasospasm following SAH is warranted.